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**We use a HIPPA compliant portal and your information is protected and secure. We will not share any of this information with anyone ever.

First Name

Last Name

Email *

Phone *

Are you seeking care for an adult (self or other) or a child?

Age (Person Applying for Care)

Gender ( Person applying for care)

Your Relationship to the Person Applying for Care (If Other)

Please attach a recent selfie picture *

Occupation

City

State

Country

Are you interested in a specific service- please select. You can choose more than one: *

Foundational Metabolic Health Consultations

Remote Neurofeedback (Myndlift)

Remote Integrated Listening Systems (iLS)

Remote Stress and Trauma Releasing Exercises (TRE)

Online Courses

Are you a former client?

Yes

If yes, when was the last time Dr. Rimka saw you

Who can we thank for your referral?

What's the main reason you are applying for care? What would you like to see improved, eliminated, or reversed? How long has this been negatively impacting your quality of life?

On a scale of 1-10, 1 being LITTLE and 10 being EXTREME, how much is this issue impacting the quality of your daily life?

What have you tried to feel better? Please list what helps and what doesn’t.

Have you ever used functional or holistic doctors outside of the traditional medical model? Please give a brief description of your experiences and types of practitioners.

What do you typically eat in a 3 day period? Please list any specific diets or restrictions you may follow such as: GAPS diet, Paleo, Vegan, Gluten-Dairy-Soy Free, Carnivore, Keto, Beef only, Hindu, Orthodox Jew, etc.

Are there any medical diagnoses being treated with therapies or medications currently?

Are you using any recreational drugs such as marijuana for sleep or pain, for example? Do you participate in psychedelic journeys? Even if you think these things are unrelated, it’s important we know all current health issues, medications, and plant guides as that can quickly determine eligibility of certain modalities. We are committed to results and not false promises. Please list them ALL along with dosages. This includes BHRT and peptide therapy.

Have you had any vaccinations, serious illnesses, surgeries, or accidents in the last 12 months?

Have you had any aesthetic treatment such as botox, chemical peels, breast implants, or filler injections? Did you undergo breast explant surgery?

Connect with us

Courses – [email protected] | Collabs - [email protected] | General – [email protected]

404-745-9233 | Mailing Address: 6526 S. Kanner Hwy #135, Stuart, FL 34997

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